South Sudan is mired in conflict. The daily realities of life in the world’s newest nation are hard to comprehend. In this blog, Seema Biswas, a field surgeon with the International Committee of the Red Cross (ICRC), shares her experiences of working in South Sudan.

This time a fortnight ago, I was waiting anxiously for a helicopter that had been despatched to take me and my colleagues back to Juba from the field.

We were leaving three days late as the rainy season makes some airstrips impassable. We waited quietly, surrounded by children sporting football shirts from around the world, as the helicopter refuelled.

I wondered whether one day I would watch one of these children wearing his own shirt and playing for South Sudan on TV.

There are no shoes to go with their football shirts and they are not all at school. Children grow up fast here.

They wade barefoot through the mud and lakes of water left after the heavy rains between May and October, and, occasionally, they’re are among the patients wounded by the fighting I have to treat.

Child victims of war

The children wounded by gunfire all have tragic stories. Their injuries are usually to their arms or legs and I have amputated, plastered, put in traction and externally fixated (attached surgical meccano) to every conceivable injury over the last three months.

Even after years of working in low-resource settings, I cannot perform an operation without wondering how different that child’s life might be away from war, in a country at peace where there is running water, electricity, roads and, of course, school for everyone.

One child, who we call ‘the baby’, but is actually nine years old, has a broken leg with an open wound. He has been with us for a few weeks. He is small for his age, attached to his mum and dad, has the sweetest face and really is the baby among those with whom he shares a tent.

What he needs is fairly simple. Sorting out the infected wound is more important initially than setting the bone, which will not heal unless we can clear the infection. Infection is the absolute enemy of the war surgeon.

So why is it so hard to treat this boy? He needs smaller instruments (small surgical meccano) than we have in our standard war surgical kits to hold the broken bones together. After all, we hope not to see children among the war wounded.

The boy needs the wound cleaned well and regularly. He cries when he sees us and so we never approach his wound without an anaesthetic. Daily anaesthesia should be avoided, yet, without the surgical meccano, the broken bones move and he is in unbearable pain.

So we agree to leave the leg in plaster and wash out the wound under anaesthesia as often as he can tolerate. But, as time presses on and the infection remains, the need to transfer him to a unit where they have small instruments becomes urgent.

Dreams in the operating theatre

There are units in South Sudan that deal with children. It is no accident that some of these are feeding centres. So many children in South Sudan look undernourished.

The rain prevents his transfer as the only transport available is by plane. What roads that exist are impassable.

In desperation, his father asks me whether they can carry him to the hospital where they have the equipment he needs. I ask how far it is. The answer: “Four days by footing (walking).” Collective sigh.

Most of the other patients are only ten or 15 years older than him. They look equally scared at the thought of needing surgery and need careful explanation through local translators.

Going to the operating theatre, the ‘OT’, is a big deal. Once in the operating theatre, their dreams under anaesthetic seem extraordinary.

We listen and wonder as they talk in their sleep. They mention all the team by name and it becomes obvious that they have got used to us and going to the operating theatre.

When it comes to going home, it is clear that for some patients, especially those who are local, getting back to family is an urgent priority.

Their families are also in the hospital. Babies sit under the beds amongst the pots of rice and beans. People are tired, exhausted from years of war and they are scared.

Beauty amid conflict

South Sudan – beautiful, green, fertile and bathed in sun – may be ripe for development but conflict continues. What goods there are in the market are flown in. It is a mystery how people can afford the prices. Everyone is slim.

The women are beautiful. I look on with jealousy at the tall, slim women with perfect skin offering to carry my bag as I stumble awkwardly through the mud. I tell myself that it is a good thing that I am struggling in the heat – I do need to lose weight.

They are as strong as they are beautiful. They carry our supplies on their heads while our cars, unable to get through the mud, remain at base camp.

They pace to the hospital and back in a fraction of the time it takes me to negotiate the first mini-lake on the way.

Many of the local staff who work with us are away from their families. Some of their families are in neighbouring countries.

They haven’t seen their families for months. They literally fled the fighting with only the shirts on their backs. Now they work with us.

It is a unique privilege to work in the operating theatre alongside a university lecturer who has no university to go back to at the moment. He does not mind being ‘the helper’ as he runs to get more saline and adjusts the light.

Now that I am back home, my mind returns to the people I met: to the patients who will have their next operation with a new team; to the children – would-be Pelés; to the models and the university lecturers in the operating theatre.

Soon the rains will stop and the dry season will begin. It will be hotter still. Life will be harder still. The airfields will be jammed with flights for food drops, relief workers and supplies.

I hope that one day soon children will be back at school, the men raising their cattle, the women growing their crops and the university lecturers teaching their students.